CASE PRESENTATION ON EARLY PREGNANCY LOSS (ABORTION)

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CASE PRESENTATION ON EARLY PREGNANCY
LOSS(ABORTION)

• MARIA MADONNA REFAMA, R.N.
• OPD-OB GYNE

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• 1. DEMOGRAPHIC DATA
• Case number 187
• Age 24 Y/O
• Sex Female
• Diagnosis G1 P0 11 weeks and 6 days AOG
  Incomplete Abortion

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• 2. PHYSICAL ASSESSMENT
• GENERAL
• Ambulatory
• Conscious and coherent
• Slightly weak
• () dizziness
• Active vaginal bleeding
• In pain presented by grimaced face and guarding
  the abdominal area.
• Vital signs
• B/P 90/60mmHg PR 90 bpm
• T 36. 5 C RR 22 bpm

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• INTEGUMENTARY
• Pale in appearance
• Cold and clammy skin
• Nail beds slightly bluish in color

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• HEAD AND NECK
• Facial symmetry
• No lesions nor masses palpated
• No deformity noted
• No palpable lymph nodes noted
• No nasal flaring, congestion or drainages noted
• Pale conjunctiva noted
• Dry and pale lips also noted

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• BODY AND UPPER/LOWER extremities
• No physical deformities, contractures nor
  paralysis noted.
• Good range of motion.

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• GENITOURINARY
• Profuse vaginal bleeding with soaked pads.
• With minimal blood clots.
• Cervix closed upon vaginal examination by SOD.
• Able to void freely in adequate amount.
• No painful sensation during urination as
  reported.

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• NEUROLOGIC
• Slightly anxious.
• Uncooperative in internal examination.
• Oriented to time, place and person.

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• 3. PATIENT HISTORY
• PAST HISTORY
• Consultation done at DAAH under Dra. Sofia dated
  17/10/12, investigations done as follows
• LMP not sure

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• SERUM B-HCG (QUANTITATIVE) RESULT 58,598 mIU/
  ml

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• Transvaginal Ultrasound
• Impression
• Anembryonic pregnancy
• 6 weeks and 5 days AOG by MSD
• No embryonic pole seen
• No yolk sac
• Irregularly shaped gestational sac
• Normal ovaries with corpus luteum on the right

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• 1 day prior to admission (03/11/12)
• () vaginal
• spotting
• Hypogastric pain

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• PRESENT HISTORY
• G1 P0 11 weeks and 6 days by UTZ
• Complaint of
• Profuse vaginal bleeding
• Hypogastric pain
• Dizziness
• Quick scan with UTZ revealed gestational sac at
  the lower uterine segment.

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• 4. TOPIC PRESENTATION
• ABORTION
• Is the spontaneous or induced loss of an early
  pregnancy.
• Any interruption of pregnancy before a fetus is
  viable or that is less than 20 weeks age of
  gestation (AOG), or that which weighs less than
  500g.
• The term miscarriage is used often in the lay
  language and refers to spontaneous abortion.

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• TYPES OF SPONTANEOUS ABORTION
• 1.Threatened Abortion
• Consists of any vaginal bleeding during early
  pregnancy without cervical dilatation or change
  in cervical consistency.
• Usually, no significant pain exists, although
  mild cramps may occur. More severe cramps may
  lead to an inevitable abortion.

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• Very common in the first trimester about 25-30
  of all pregnancies have some bleeding during the
  pregnancy.
• Less than one half proceed to a complete
  abortion.
• On examination blood or brownish discharge may
  be present in the vagina. The cervix is not
  tender, and the cervical os is closed. No fetal
  tissue or membranes have passed.
• The ultrasound shows a continuing intrauterine
  pregnancy.

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• 2. Inevitable Abortion
• An early pregnancy with vaginal bleeding and
  dilatation of the cervix.
• Typically, the vaginal bleeding is worse than
  with a threatened abortion, and more cramping is
  present.
• No tissue has passed yet.
• On ultrasound, the products of conception are
  located in the lower uterine segment or the
  cervical canal.

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• 3. Incomplete Abortion
• A pregnancy that is associated with vaginal
  bleeding, dilatation of the cervical canal, and
  passage of products of conception.
• Usually, the cramps are intense, and the vaginal
  bleeding is heavy.
• With passage of tissue within the vagina.
• Ultrasound may show that some of the products of
  conception are still present in the uterus.

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• 4. Complete Abortion
• A history of vaginal bleeding, abdominal pain,
  and passage of tissue exists.
• After the tissue passes, the patient notes that
  the pain subsides and the vaginal bleeding
  significantly diminishes.
• The examination reveals some blood in the vaginal
  vault a closed cervical os and no tenderness of
  the cervix, uterus, adnexa, or abdomen.
• The ultrasound demonstrates an empty uterus.

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• Anembryonic gestation
• (also known as a blighted ovum) is a pregnancy
  in which the very early pregnancy appears normal
  on an ultrasound scan, but as the pregnancy
  progresses a visible embryo never develops. In a
  normal pregnancy, an embryo would be visible on
  an ultrasound by six weeks after the woman's last
  menstrual period.
• Anembryonic gestation is one of the causes of
  miscarriage of a pregnancy.

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• 5. ANATOMY AND PHYSIOLOGY

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PATHOPHYSIOLOGY AND ETIOLOGY
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EARLY PREGNANCY
RISK FACTORS
MATERNAL/ PARENTAL FACTORS
LIFESTYLE
ENVIRONMENTAL FACTORS
AGE POOR NUTRITIONAL STATUS POOR IMMUNE
SYSTEM W/ UNDERLYING DISEASE OR CONDITION
USE OF ALCOHOL PROHIBITED DRUGS SMOKING
EXPOSURE TO RADIATION TERATOGENS
AUTOIMMUNE (APAS)
CHROMOSOMAL ABNORMALITIES
INFECTION
SIGNS SYMPTOMS LOWER BACK PAIN VAGINAL
BLEEDING ABDOMINAL CRAMPS
HIGH RISK PREGNANCY
MISCARRIAGE
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UTERINE
CRAMPING LOWER BACK PAIN
7. SIGNS AND SYMPTOMS



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VAGINAL
BLEEDING

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• 8. NURSING
• INTERVENTIONS
• Monitor vital signs.
• Monitor vaginal bleeding through pad count.
• Promote bed rest.
• Provide fluid resuscitation.
• If considerable amount of blood loss has
  occurred, aggressive hydration, iron therapy or
  transfusions may be indicated.
• Prevent infection.
• Provide emotional support.

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• 9. TREATMENT
• MEDICAL
• COMPLETE ABORTION usually needs no further
  treatment, medically or surgically.
• THREATENED ABORTION- use of progestogen.
• MISOPROSTOL is an effective medical therapy. It
  increase uterine smooth muscle contractions and
  soften the cervix to allow passage of products of
  conception from missed abortion, inevitable
  abortion, or incomplete abortion.
• Risks for medical therapy include bleeding,
  infection, possible incomplete abortion, and
  possible failure of the medication to work.

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• SURGICAL
• Inevitable and incomplete abortions are typically
  treated surgically with DC.
• Methylergonovine maleate (Methergine) (0.2 mg
  IM)- given after DC to contract the uterus.
  This will also decrease the likelihood that clots
  will be retained in the uterus.
• Risks of a DC include bleeding, infection,
  possible perforation of the uterus, and possible
  Asherman syndrome after the procedure.

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• 10. COMPLICATIONS
• Hemorrhage
• High fever due to infection.
• Maternal mortality.
• Accumulation of clot in the uterine cavity
  without expulsion due to uterine atony.

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• 11. PRIORITIZATION OF NURSING PROBLEMS
• Fluid volume deficit related to profuse vaginal
  bleeding secondary to incomplete abortion.
• B. Acute pain related to uterine cramping
  secondary to expulsion of some products of
  conception.
• C. Anticipatory grieving related to loss of
  pregnancy.
• D. Risk for infection related to dilated cervix
  and open uterine vessels.

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12. NURSING CARE PLAN
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ASSESSMENT ASSESSMENT PLANNING IMPLEMENTATION IMPLEMENTATION EVALUATION
CUES/ EVIDENCE NURSING DIAGNOSIS GOALS AND DESIRED OUTCOME NURSING INTERVENTIONs RATIONALE FOR INTERVENTION EVALUATION
SUBJECTIVE I felt dizzy and I consumed 5-6 pads today and its fully soaked. OBJECTIVE Profuse vaginal bleeding with soaked pad and with minimal blood clots. Skin pallor noted. Bluish nail beds. Cold and clammy skin. Dry oral mucous membranes. V/S as follows BP- 90/60mmHg T- 36. 5 C PR- 90, bpm RR- 22 bpm Fluid volume deficit related to profuse vaginal bleeding secondary to incomplete abortion. After 6-8 hours of nursing intervention the patient will be able to demonstrate improve fluid balance as evidence by minimal vaginal bleeding, good skin turgor, diminish pallor. INDEPENDENT Assessed the stability of the patient through monitoring vital signs. Inserted gauge 18 of cannula at the left metacarpal vein. Instructed the patient to do pad counts. Maintained bed rest and assisted in ADL. Schedule activities to undisturbed rest periods. DEPENDENT Administered fluids as ordered. Hgb, Hct, RBC monitored. Provide baseline data regarding patients condition. IV line is needed for the hydration of the patient to replace the blood loss. To monitor the bleeding and able to assess the blood loss. Activity increases intra-abdominal pressure that may cause further bleeding and also to promote fast recovery. To replace fluid loss and aids in fast recovery. Through laboratory results we can see the effectiveness of the theraphy. After 6-8 hours of nursing interventions the goals were met as evidenced by Scanty vaginal bleeding. Good skin turgor and color. Fast capillary refill lt2 sec V/S stable BP- 110/70mmHg T- 36. 9 C PR- 80 bpm RR- 20 bpm
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• 13. NURSING HEALTH TEACHING
• Explained to the patient the need to wait for at
  least 3-6 months before attempting another
  pregnancy.
• Reinforced or discussed with the couple the
  methods of contraception to be used.

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• Instructed the couple to observe for signs of
  infection such as fever, pelvic pain, and change
  in character or amount of vaginal discharge and
  advise to report them immediately.
• Explained to the patient the importance of follow
  up check-up to monitor the presence of bleeding
  and contraction of the uterus after DC.
• Emphasized the importance of take home
  medications prescribed by the physician.

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• 14. CONCLUSION
• First Trimester/early pregnancy is the most
  crucial stage of pregnancy in which the mother
  must have a closed watch or gives much attention
  to. Therefore I conclude that Antenatal check-up
  during pregnancy is important to monitor the
  status of the fetus and the mother. Any presence
  of unusual signs and symptoms must be reported
  immediately.

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• If in any case pregnancy loss is inevitable
  immediate action is needed, any delay may result
  to infection or further complications to mother.
• As a nurse, we need to encourage pregnant women
  to have their routine check-ups to prevent any
  complications during or throughout their
  pregnancy. Importance of vitamins and other
  pregnancy supplements should be emphasized.
  Medical team stands an important role in human
  well-being. The role of a healthcare provider
  must not just within the hospital but also in the
  home wherein provided health teachings must be
  implemented.

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• 15. BIBLIOGRAPHY
• 1. Philippine Obstetrical and Gynecological
  Society (Foundation), Inc.
• Clinical Practice Guidelines on Abortion
  (November 2010)
• Pages 1-15
• 2. Lippincott Manual of Nursing Practice 9th
  Edition pages 1316, 1317, 1318
• 3. Maternal and Child Health Nursing by Adele
  Pillitteri 5th Edition pages 400-409
• 4. http//www.scribd.com/doc/15991947/Nursingcribc
  om-Spontaneous-Abortion
• 5. http//nursingcrib.com/nursing-notes-reviewer/m
  aternal-child-health/spontaneous-abortion/
• 6.http//nursingcrib.com/nursing-notes-reviewer/fu
  ndamentals-of-nursing/nursing-diagnosis-for-female
  -reproductive-diseasesdisorders/
•  
•  

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7. http//nursingcrib.com/nursing-care-plan/nursi
ng-care-plan-dilatation-and-curettage-d-c/   8.
http//emedicine.medscape.com/article/795085-overv
iew   9. http//emedicine.medscape.com/article/795
085-clinical   10.http//www.rightdiagnosis.com/m/
miscarriage/complic.htm   11. http//arispestanyo.
hubpages.com/hub/nursing-care-plan-abortion 12.
http//www.healthplus24.com/womens-health/miscarri
age.aspx  
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